Will Patient Care Be Capped in 2003? ASHA Seeks to Extend Moratorium on Medicare Caps, but Outlook Uncertain Policy Analysis
Policy Analysis  |   October 01, 2002
Will Patient Care Be Capped in 2003?
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Regulatory, Legislative & Advocacy / Policy Analysis
Policy Analysis   |   October 01, 2002
Will Patient Care Be Capped in 2003?
The ASHA Leader, October 2002, Vol. 7, 1-8. doi:10.1044/leader.PA.07192002.1
The ASHA Leader, October 2002, Vol. 7, 1-8. doi:10.1044/leader.PA.07192002.1
As the end of 2002 approaches, so does the end of the three-year breather from the Medicare Part B caps on outpatient services. The harshest of these caps is the limit imposed on speech-language pathology and physical therapy services, which are combined into a single $1,500 cap. If Congress doesn’t act soon, the caps will return on Jan. 1, 2003.
ASHA and other organizations have launched an all-out effort to convince legislators to repeal the $1,500 caps. However, the outcome is highly uncertain with looming budget deficits, midterm elections, and ongoing debate about Iraq.
“We’ve succeeded in getting the moratorium language into both the House and Senate Medicare bills, but the fate of those bills is subject to larger political forces,” notes ASHA lobbyist Reed Franklin, who adds that 30-year Capitol Hill veterans have commented that the level of uncertainty in this congressional session is unprecedented.
Sen. Max Baucus (D-MT), finance chair, says the “issue is urgent, as some provider payment cuts began to take effect Oct. 1.”
At press time, Senate Democratic leaders unsuccessfully tried to get the two-year extension of the cap moratorium approved by unanimous consent.
Despite these obstacles, “The letters and phone calls from ASHA members to repeal the caps have had a big impact, and we need to keep up the effort,” Franklin says.
Clinicians Speak Out
At work in clinical settings far from Capitol Hill, speech-language pathologists are speaking out on the negative impact the caps will have on patients if they return—especially on the many Medicare beneficiaries who suffer strokes. Currently, 500,000 people of all ages suffer a stroke every year, and stroke accounts for more than half of all patients hospitalized for neurological disease, according to the American Stroke Association.
Gayle Burditt, an SLP in private practice in Washington state, says, “To restrict services based on governmental monetary regulation instead of a patient’s treatment requirements is not only immoral, but demoralizing for the patient.”
For Gail Neustadt, a Pennsylvania SLP, the cap unfairly penalizes beneficiaries with acute therapy needs. She says the speech-language pathology/physical therapy cap “hits the geriatric population and those with long-standing disabilities. It is prejudicial against our most vulnerable citizens who have paid for Medicare through their earned dollars.”
She adds, “The geriatric population is at risk for multiple and chronic disorders that may lead to unnecessary decline in functional abilities without adequate, reasonable, and necessary rehabilitative services.”
The $1,500 provided by Medicare cannot adequately cover needed therapy services, Neustadt believes. Since spontaneous recovery after an acute stroke can take up to six months, treatment will need to be continued beyond the 100 days allocated under Medicare Part A.
Patients who return home will require more than 20 sessions of speech services, across an average of 30 days, for a communication and/or swallowing disorder. “This alone would exceed $1,500 in services,” she says.
In addition to communication and swallowing problems, the stroke client often has gait disturbances and cannot walk independently. If the $1,500 allocation were evenly split, Neustadt says each discipline could provide treatment for a combination of no more than five speech evaluations and treatments and six physical therapy visits.
“This conflicts with the OBRA-87 congressional mandate requiring that nursing facility residents reach their highest functional level,” she says. “The cap also creates tension among members of the rehabilitation interdisciplinary team.”
Another problem, Neustadt says, is that family members often place more emphasis on “walking than talking,” and may choose physical therapy over communication or swallowing services.
She describes one possible scenario where the stroke patient whose communication needs are not addressed can then develop behavioral problems that may be addressed pharmacologically, often causing balance and gait side effects that can set back the patient’s physical therapy process.
Of course, no patient should have to choose whether to walk or talk, particularly when they, and their family members, are facing complex medical uncertainties and diagnosis (see sidebar at right).
Although Congress created the caps to stop potential Medicare abuses, Neustadt questions the assumption of fraud.
“The government doesn’t have a process to track the $1,500 expenditure,” she says, adding that such a system would be costly. “Rather than using tax dollars to police a regulation that is harmful to our geriatric population, the government could fund medically reasonable and necessary rehabilitation services.”
Staying the Course
Joanne Wisely, manager of regulatory affairs for Genesis Rehabilitation Services, which operates in 19 states, agrees the fear of widespread fraud is overblown. She cites a survey that the National Association for the Support of Long Term Care conducted when the caps were in place and during the moratorium, which found that only 12% of patients consistently exceeded the $1,500 for services.
“We are not abusing the cap, even during the moratorium,” Wisely observes.
She recently participated in a “fly-in” to Capitol Hill for managers from multi-state health care companies, which included—she was pleased to see—several fellow SLPs. They spoke to members of Congress on behalf of their clients, their profession, and the industry on the importance of ending the caps.
Wisely echoes ASHA’s emphasis on the grassroots activism.
“You cannot write too many letters, make too many visits, or sign too many petitions. The more people you call, the better chance you have,” she says. “SLPs need to keep a clinical perspective regardless of what happens, and we have to stay the course.”
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October 2002
Volume 7, Issue 19